[A case of an aged patient suspected of craniopharyngioma with a chief symptom of eunuchoidism accompanied with panhypopituitarism]

A 78-year-old man with developmental disturbance of the genital organs and eunuchoidism was reported. He also had a high pitched voice, thickness of the lower lip and kyphosis of the thorax. He seemed to be fretful, but his intelligence was normal. Neurological tests revealed bilateral hemianopsia and decreased tendon reflexes. A plain skull radiograph clearly showed an egg shaped calcified mass extending upward from the sella turcica which resembled a ballooning shape. Brain CTs showed a high density round mass which expanded the sella turcica and raised the floor of the third ventricle. The inner part of the tumor showed irregular high density. T1-weighted MR imaging revealed an iso signal intensity, and T2 showed low signal intensity in the mass. These findings strongly supported the diagnosis of calcificated craniopharyngioma. Endocrinological study showed panhypopituitarism caused by the tumor compressing the pituitary gland and the hypothalamus. The main reasons why there were no apparent symptoms of hypopituitarism were because the receptors were up-regulated and secondarily because the thyroid and the adrenal cortical functions decreased while struggling to maintain balance with each other. There was also a possibility that these symptoms might have been masked by normal aging. Benign monoclonal hypergammopathy was also indicated, although we could not find a clear correlation between this finding and others.

[Five year follow-up study on dementia in institutions for the elderly]

The purpose of this study was to clarify the prognosis of senile dementia based on a 5-year follow-up study in institutions for the elderly. The subjects consisted of 747 cases over 60 years of age. Of these 316 cases showed clinical dementia but 431 cases had no intellectual disturbance in July, 1987. The mortality rate (56.3%) of the demented group was significantly higher than that (31.8%) of the non-demented group. The mortality rate of patients increased with aging. However, the mortality rate of the demented group did not correlate with the severity of dementia. An autopsy study revealed that the direct causes of death in 51.1% of demented patients were pneumonia and cardiovascular diseases. Among the demented patients followed up for 5 years, 22.5% showed severe worsening of dementia, 25.8% showed slight or moderate degree of worsening and 51.7% showed no change. Factors causing exacerbation of dementia included cerebrovascular disease and bone fracture.

[A case of brain dead patient with a spinal pathology of preserved marginal white matter and pencil-shaped softening--a theory for pathogenesis of pencil-shaped softening]

We reported a case of brain death which had been caused by massive cerebral hemorrhage. The spinal pathology showed preserved marginal parts of spinal white matter in the segments of C7 to T5 and S1 to S3, and the other parts showed necrosis. We found pencil-shaped softening (PS)-like lesion in the segment C8 to T2, but the lesion was more preserved than the surrounding tissue. The intraspinal structure of C5 was distorted by the necrotic cerebellar tissue in the subarachnoid space of the segment and the posterior column area was decreased. The posterior column in C5 and PS showed the same severe pathology. Because the pia mater of the spinal cord is not so easily torn, and has some elasticity, swollen spinal necrotic tissue has no place to move but in a longitudinal direction; that circumstance may cause the PS. In this case the subarachnoid cerebellar tissue restricted the expansion of the spinal cord in C5, which might have helped cause PS. So we suggest that the subarachnoidal cerebellar tissue and changes of antero-posterior diameter in the spinal column, when the spine is flexed or extended, may contribute to the pathogenesis of PS. In this case the pathology of the PS was reversed as compared to the usual PS, because the PS was relatively preserved while the surrounding tissue was necrotic. There have been only a few reports which show preserved marginal white matter of the spinal cord.(ABSTRACT TRUNCATED AT 250 WORDS)

Purification and structural analysis of hippocampal cholinergic neurostimulating peptide

Hippocampal soluble fraction stimulates acetylcholine (AcCho) synthesis of medial septal nuclei in explant culture system. This stimulating activity was purified from 10-12-day-old rat hippocampus. During purification, the activity was separated into two fractions and a previously unreported peptide was purified from one fraction. The structure of this novel peptide is acetyl-Ala-Ala-Asp-Ile-Ser-Gln-Trp-Ala-Gly-Pro-Leu and we designated it as hippocampal cholinergic neurostimulating peptide (HCNP). Synthesized HCNP and de-acetylated HCNP (free-HCNP) stimulated AcCho synthesis of medial septal nuclei culture, in a dose-dependent manner, but not cultures of corpus striatum or anterior spinal cord. Mean half-maximal concentrations of HCNP and free-HCNP in AcCho synthesis of medial septal nuclei culture were 1.0 +/- 0.3 x 10(-10) M and 1.0 +/- 0.6 x 10(-11) M, respectively. Affinity purified polyclonal antibody to the free-HCNP neutralized the activity of crude hippocampal extract, as well as synthetic HCNP and free-HCNP. These observations suggested that HCNP was present in the hippocampal extract and was involved in development of specific cholinergic neuron in central nervous system.

[Bedridden elderly and dementia]

The purpose of this study is to clarify possible correlations between dementia and long term bedridden elderly patients in our special nursing home and geriatric hospital. At the time of our study, 42.6% of all our patients were bedridden, and the ratio increased in those groups of advanced age. The percentage of bedridden female patients was higher than that of males. Most bedridden patients, suffered disorders of the nervous system particularly disorders caused by cerebrovascular disease. Among the bedridden patients, the incidence of dementia was 82.8%. In most these cases, the degree of dementia was severe. The types and respective percentages of dementia were as follows: Vascular type 45.1%, Alzheimer's type 23.2%, mixed type 19.5% and others 12.2%. We think that Alzheimer's type dementia may cause a patient to become bedridden. On the other hand, vascular type dementia may be promoted by a patient's being bedridden for a long time. Tube-fed patients comprised 20% of all bedridden patients and all of these patients showed dementia. We believe that a patient's getting out of bed and receiving rehabilitation as soon as possible is vital to the prevention of becoming permanently bedridden. In respect to the present study of bedridden dementia patients, we would like to further study tube feeding and terminal care.

[A case of cerebral infarction with circulating anticoagulant to Fletcher factor]

A 44-year-old woman with a history of cerebral infarction and hypertension developed sudden onset of speech and visual disturbance. On admission, her general physical examinations showed high blood pressure of 210/120 mmHg and Raynaud's phenomena. The neurological examinations revealed right upper quadratic hemianopsia, left oculomotor nerve paresis and left hyperreflexia. Laboratory findings showed that antinuclear and anti-DNA antibodies were positive. The activity of Fletcher factor was reduced to 50%, and the activated partial thromboplastin time (APTT) was prolonged to 82.6 seconds. And a 1:1 dilution with normal plasma failed to correct the prolonged APTT, indicative of circulating anticoagulant to Fletcher factor. Plasma fibrinogen increased to 500 mg/dl but FDP was normal. The CT scan demonstrated the recurrently developed cerebral infarction in the left occipital lobe. Cerebral angiogram revealed mild atherosclerosis of basilar and bilateral posterior cerebral arteries, but any occlusive lesions were not found. Although she had a history of hypertension, this case suggests the possibility that the disturbance in fibrinolytic system may have been caused by the circulating anticoagulant to Fletcher factor, and contributed to her cerebral infarctions.

[An autopsy case of progressive supranuclear palsy with central pontine myelinolysis]

An autopsy case of progressive supranuclear palsy (PSP) associated with central pontine myelinolysis (CPM) is reported. A 73-year-old male patient suffered from gait disturbance for about 5 years. The clinical features were characterized by gradual development of supranuclear ophthalmoplegia, tremor, bradykinesia, rigidity, neck dystonia, dementia and pseudobulbar palsy at the advanced stage of his illness. Treatment with levodopa did not improve his neurological signs and symptoms. PSP or multiple system atrophy was considered as a clinical diagnosis of the patient. He died of pneumonia, acute pancreatitis and liver dysfunction in November 1985. The main neuropathological findings were neuronal loss and gliosis with neurofibrillary tangles of globose type in the globus pallidus, subthalamic nucleus, substantia nigra and dentate nucleus, and at the base of the pons, bilateral and symmetrical demyelination was found. In addition, myelin staining revealed circumscribed pallor in the cerebral white matter. The histologic diagnosis was PSP associated with CPM. An association of PSP with CPM is rare in the elderly and possible etiologic factors of both diseases were discussed.

[Effect and prognosis of rehabilitation for cerebrovascular dementia in the elderly]

The effect of rehabilitation and prognosis for elderly cases of cerebrovascular dementia were evaluated by comparing the group of the patients receiving rehabilitation with those who did not receive rehabilitation. There were no significant differences in the age, neurological symptoms, psychotic symptoms, physical complications, ADL and Hasegawa's dementia rating scale between the two groups. The main reason for rehabilitation was recurrence of cerebrovascular attack (42.9%), disuse atrophy (42.9%) and bone fracture and others (14.3%). There was significant improvement of ADL in the patients showing a score of more than 10 on Hasegawa's dementia rating scale and in the patients given drugs to improve cerebral circulation and metabolism, but there was no significant improvement of Hasegawa's dementia rating scale. Concerning the prognosis of patients receiving the rehabilitation, there was no change of ADL and Hasegawa's dementia rating scale. In the group of patients which did not receive rehabilitation, significant decrease of ADL was noted, but there was no change of Hasegawa's dementia rating scale.

Neurotrophic effects of hippocampal extracts on medial septal nucleus in vitro

Within peripheral sympathetic and sensory systems, target tissue provides diffusible factors such as nerve growth factor that influence neuronal survival, growth, and differentiation. To determine whether target tissue may exert retrograde effects within the central nervous system, we have used hippocampus as a source of neurotrophic factors and cultured medial septal nucleus explants as a source of neurons that may respond to such factors. Soluble extracts from rat hippocampus enhance cholinergic activity (choline acetyltransferase, choline uptake, acetylcholine synthesis) of the rat medial septal nucleus cultured in serum-free defined medium. The enhancement is dose dependent, relatively specific for hippocampus, and varies with age, reaching a peak in 2- to 3-week-old rat hippocampus. The enhancing activity of the hippocampal extract appears to be mediated by protease-sensitive polypeptide(s) that differ from nerve growth factor in biological and chemical characteristics.